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Original Articles: Adult Cardiac

Invited Commentary

Department of Thoracic and Cardiovascular Surgery, Rikshospitalet, Norway

(Email: j.l.svennevig{at}klinmed.uio.no).

The authors of this article [1] compare early and 1-year results for two groups of patients undergoing coronary artery bypass grafting (CABG): group A includes 111 patients with EuroScore >12 receiving an intra-aortic balloon pump (IABP) preoperatively, and group B includes 130 patients with EuroScore < 5 serving as controls. The authors are well aware of the limitations of this approach; however, they do not consider randomization to be an acceptable alternative. I agree.

A true control group would mean randomization of high-risk patients to preoperative IABP or not, which would create ethical problems. The use of a historical control group would have to deal with changes in the CABG population as well as in perioperative protocols over time. The study includes on-pump and off-pump patients. This may represent another limitation. However, the size of the material does not support subgroup analysis.

I am surprised that so many patients in group B had inotropic support. This seems to be based on the institutions protocol rather than on strict criteria defining the need for support. Previous reports from single institutions have documented the beneficial effect of preoperative IABP in high-risk patients undergoing CABG [2, 3]. A recent meta-analysis based on 10 publications concludes that there is evidence that preoperative IABP in high-risk patients reduces hospital mortality [4]. A 10-year follow-up study from our own institution identified the timing of IABP insertion to be an independent prognostic factor also for late death [5].

The present study by Santarpino and coworkers [1] is well done, the outcome variables are well defined, and the discussion is relevant. Although there are major differences in the risk profile between the two groups, the operative variables are comparable. Postoperatively, there are no differences regarding morbidity, mortality, and myocardial damage. Based on these results one should consider the routine use of preoperative IABP in all high-risk patients undergoing CABG based on a certain EuroScore. Further studies will be needed to evaluate the benefit of this approach and to establish defined limits for the use of IABP preoperatively, considering costs and possible complications.

	References

Top References

 

1. Santarpino G, Onorati F, Rubino AS, et al. Preoperative intraaortic balloon pumping improves outcomes for high-risk patients in routine coronary artery bypass graft surgery Ann Thorac Surg 2009;87:481-488.[Abstract/Free Full Text]
2. Gutfinger DE, Ott RA, Miller M, et al. Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass grafting Ann Thorac Surg 1999;67:610-613.[Abstract/Free Full Text]
3. Christenson JT, Simonet F, Badel P, Schmuziger M. Optimal timing of intraoperative balloon pump support in high-risk coronary patients Ann Thorac Surg 1999;68:934-939.[Abstract/Free Full Text]
4. Dyub AM, Whitlock RP, Abouzahr LL, Cina CS. Preoperative intra-aortic balloon pump in patients undergoing coronary bypass surgery: a systematic review and meta-analysis J Card Surg 2008;23;:79-86.[Medline]
5. Arafa OE, Pedersen TH, Svennevig JL, Fosse E, Geiran OR. Intraaortic balloon pump in open heart operations: 10-year follow-up with risk analysis Ann Thorac Surg 1998;65:741-747.[Abstract/Free Full Text]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jan Ludvig Svennevig Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Svennevig, J. L. Search for Related Content PubMed PubMed Citation Articles by Svennevig, J. L. Related Collections Coronary disease Related Article